Important Numbers 3 Regional Programs telephone and fax numbers have been updated. Health Care Facility 5, 14 Calvert Memorial Hospital CalvertHealth Medical Center Health Care Facility 6 Code 239 Frederick Memorial Hospital (Base Station, Cardiac Interventional, Perinatal) Frederick Memorial Hospital (Base Station, Cardiac Interventional, Perinatal, Primary Stroke) Health Care Facility 6 Code 297 Easton (UMSRH) (Base Station, Primary Stroke) Easton (UMSRH) (Base Station, Primary Stroke, Cardiac Interventional) Health Care Facility 7 Code 352 Laurel Regional Hospital Laurel Regional Hospital (Base Station) (NEW 18) Health Care Facility 7 Code 360 Southern Chester County Medical Center, PA (pg. 10) Now known as Jennersville Regional Hospital (moved to page 7) Health Care Facility 10 Code 360 Southern Chester County Medical Center, PA (pg. 10) Now known as Jennersville Regional Hospital (moved to page 7) Maryland Trauma and 15 Added Shore Medical Center at Easton (UM) to Cardiac Interventional list Specialty Referral Centers General Patient Care 30 4.a)(3) Patients greater than 13 years of age, refer to the Universal Algorithm for Adult Emergency Cardiac Care for BLS. Patients 13 years of age or greater, refer to the Universal Algorithm for Adult Emergency Cardiac Care for BLS. General Patient Care 31 5.b)(2)(e) Distracting Injury Added definition of distracting injury. General Patient Care 35 E. 3. Added instructions Providers should obtain and document a contact telephone number for one or more individuals who have details about the patient s medical history so that the physician may obtain and validate additional patient information. Altered Mental Status: Seizures 43 through 45 3. Treatment treatment section reformatted. No changes to patient care (except pg. 44, letter k (see below)). Altered Mental Status: Seizures 44 k The paramedic may assist patients with the administration of their prescribed benzodiazepine ALS providers may assist patients with the administration of their prescribed benzodiazepine Cardiac Emergencies: 51 Complete revision Cardiac Guidelines Universal Algorithm for 53 Revised to meet current Adult Emergency Cardiac Care Cardiac Emergencies: Bradycardia 56 through 58 Added 4. Continue General Patient Care to pg. 56; renumbered algorithms. Pediatric Bradycardia Algorithm 58 (e) Medical Consult required for administration of calcium chloride Medical consultation requirement has been removed. This change also applies to all instances where medical consultation appears for calcium chloride administration in the document, specifically on pages 61, 64, 65, 66, 87, 88, 119, 120, 211, 216, and 231. Adult Tachycardia Algorithm Cardiac Emergencies: Cardiac Arrest Adult Asystole Algorithm 61 c) through g) c) - Consider calcium chloride 500 mg IVP for hypotension induced by diltiazem. If rate does not slow in 15 minutes, administer a second dose of diltiazem (15 25 mg over 2 minutes). Medical consultation required. 63 64 Intubate 02 (90%-100%) Assure Adequate Ventilation c) - Consider calcium chloride 500 mg IVP for hypotension induced by diltiazem. d) - If rate does not slow in 15 minutes, administer a second dose of diltiazem (15 25 mg over 2 minutes). Medical consultation required. Remaining instructions were renumbered. Numerous revisions Page 1 of 8
Pediatric Cardiac Arrest Algorithm Adult Pulseless Electrical Activity Ventricular Fibrillation Pulseless Ventricular Tachycardia Ventricular Fibrillation Pulseless Ventricular Tachycardia Return of Spontaneous Circulation (ROSC) Termination of Resuscitation (Medical and Traumatic) EMS DNR/MOLST Environmental Emergencies: Heat- Related Emergencies Overdose/Poisoning: Carbon Monoxide/Smoke Inhalation Overdose/Poisoning: Ingestion Excited Delirium Syndrome Excited Delirium Syndrome 65 Begin CPR Attach monitor Begin CPR Assure Adequate Ventilation Attach monitor 66 Intubate Assure Adequate Ventilation 67 Perform CPR until defibrillator is attached Perform CPR and assure adequate ventilation 67 Intubate Removed 68-69 Numerous revisions 70 through 72 74 through 77, 80, 83 102 2.a) Heat Cramps: Moist, cool skin temperature, cramps, normal to slightly elevated temperature Numerous revisions, including the algorithm Removed all references to the EMS/DNR program booklet Heat Cramps: Moist, cool skin, cramps, normal to slightly elevated temperature 115-2 o) (2) (d)-(j) o) (2) Outline reformatted to o) (2). 118-120 Reformatted. Changes in naloxone dosing (see spreadsheet pgs. 3-4) 127 through 128 Multiple Alerts In all instances, "benzodiazepines" replaced with "medication." 128 through 3. d)-m) Multiple lines Revision of adult and pediatric ALS treatment 129 Pain Management 131 e)(1)(b) Removed the word "opioid" Pain Management 132 (3) (b) (c) (e) Ketamine added. IO route of administration added for fentanyl. and (f) Pain Management 133 4. through 6. Use opioid analgesia with caution in the management of patients with altered mental status. Reformatted. Transport removed. Removed the word "opioid" from 2nd alert, third paragraph: Use analgesia with caution in the management of patients with altered mental status. Added Continue General Patient Care. Allergic Reaction 135 f), h), and i) Greater than 5 years of age: 0.5 mg in 0.5 ml IM 5 years of age of greater: 0.5 mg in 0.5 ml IM Anaphylaxis 137 d)(1) 0.3 mg IM in the lateral thigh via epinephrine auto-injector or Epinephrine (1:1,000) 0.5 mg in 0.5 ml IM epinephrine (1:1,000) 0.5 mg in 0.5 ml IM Asthma/COPD 139 3. j. and k. Removed the word "OR" between instructions in j) and k) Asthma/COPD 140 3. u) and v) Changed the order of instructions by switching verbiage in u) and v). No changes made to patient care. Sepsis: Adult 148 h) Reformatted and added letter h). Stroke: Neurological Emergencies 152 3. b) Added instructions Providers should obtain and document a contact telephone number for one or more individuals who have details about the patient s medical history so that the physician may obtain and validate additional patient information. Page 2 of 8
Stroke: Neurological Emergencies Stroke: Neurological Emergencies Stroke: Neurological Emergencies Trauma Protocol: Hand/Upper/Lower Extremity Trauma Trauma Protocol: Spinal Protection 153 3. j) Added instructions Providers should obtain and document a contact telephone number for one or more individuals who have details about the patient s medical history so that the physician may obtain and validate additional patient information. 152 through Algorithm Algorithm moved to end of 155 152 through ALERT Designated Stroke Center Designated Acute Stroke Ready, Primary, or Comprehensive Stroke Center 155 162 3.d) and 3.i) Administer opioid per Pain Management Protocol. Replaced the word "opioid" with "analgesia": Administer analgesia per Pain Management Protocol. 167 2. Presentation "Spinal Protection" (1) Midline spinal pain, tenderness, or deformity (3) Focal neurological deficit a) "Full Spinal Protection" c)(1)(a) Midline cervical, thoracic, or lumbar spinal pain, tenderness, or deformity c)(1)(c) Focal neurological deficit (sensory or motor) section also reformatted; no other changes to patient care Trauma Protocol: Spinal 171-1 New Algorithm Protection Algorithm Trauma Protocol: 172 through Complete revision Trauma Arrest 173 Appendices: Glossary 175 Alternative Airway Device An airway adjunct other than an endotracheal tube that may include dual lumen airways (e.g., EasyTube ) or the laryngeal tube airway device (e.g., King LTS-D ) An airway adjunct other than an endotracheal tube that may include the laryngeal tube airway device (e.g., King LTS-D ) or laryngeal mask airway with design to facilitate hospital endotracheal intubation Procedures, Medical 182 Intranasal Changed from OSP to SO for EMR Procedures, Medical 182 Alternative EasyTube King Airway Airway Device Procedures, Medical 182 Laryngeal Tube Airway (King LTS-D ) Laryngeal Mask Airway Device Procedures, Medical Procedures, Medical Procedures, Medical BLS Pharmacology: Naloxone (Narcan) Public Safety 183 Monitors Apnea Monitors Fixed a formatting error. 184 Calcium Chloride (10% Solution) CRT-I (MC) PM (MC) CRT-I (SO) PM (SO) 184 Naloxone EMR (OSP) EMR (SO) 193 Public Safety Public Safety and EMR Page 3 of 8
BLS Pharmacology: Naloxone (Narcan) Public Safety Dextrose Epinephrine 1:10,000/1:1,000 Epinephrine 1:10,000/1:1,000 Epinephrine 1:10,000/1:1,000 Fentanyl Haloperidol (Haldol) Ketamine Multiple pages Midazolam Midazolam Morphine Sulfate 193 g) (1)-(2) (1) Adult: Administer 2 mg IN. Divide administration of the dose equally between the nares to a maximum of 1 ml per nare. (2) Pediatric: (a) Child 5 years of age to adult: Administer 2 mg IN. Divide administration of the dose equally between the nares to a maximum of 1 ml per nare. (b) Child 28 days of age to 4 years of age: Administer 0.8 1 mg IN. Divide administration of the dose equally between the nares to a maximum of 1 ml per nare. 213 through 214 g) (2) (b) Patients 28 days or greater up to the 18th birthday - if blood glucose is less than 70 mg/dl, administer 2 4 ml/kg of 25% dextrose IV/IO to a maximum of 25 grams. D25W is prepared by mixing one part of D50W with an equal volume of LR. Page 4 of 8 (1) Adult: Administer 2 mg IN, dividing administration of the dose equally between the nares to a maximum of 1 ml per nare, OR administer 4 mg/0.1 ml IN in one nare. (2) Pediatric (child aged 28 days to adult): Administer 2 mg IN, dividing administration of the dose equally between the nares to a maximum of 1 ml per nare, OR administer 4 mg/0.1 ml IN in one nare. This new dosing regimen appears in multiple places throughout the s, specifically on pages 46, 47, 116, 117, 118, 119, 123, 124, 374, 375, 376, 377, and 378. (b) Patients 28 days up to 4 years - if blood glucose is less than 70 mg/dl, administer 2 4 ml/kg of 10% dextrose IV/IO to a maximum of 25 grams. Recheck glucose after first dose. If blood glucose is less than 70 mg/dl, obtain medical consultation to administer second dose of D10W. (i) If unable to start IV and blood glucose is less than 70 mg/dl, administer 0.5 mg glucagon IM/IN. (ii) Medical consult for additional dosing to a maximum of 3 mg IM/IN (c) Patients 5 years up to patient s 18th birthday - if blood glucose is less than 70 mg/dl, administer 2 4 ml/kg of 10% dextrose IV/IO to a maximum of 25 grams. Recheck glucose after first dose. If blood glucose is less than 70 mg/dl, obtain medical consultation to administer second dose of D10W. (i) If unable to start IV and blood glucose is less than 70 mg/dl, administer 1 mg glucagon IM/IN. (ii) Medical consult for additional dosing to a maximum of 3 mg IM/IN 220 c) Added new indication: (6) Dopamine replacement indications for epinephrine drip 221 g)(1)(a)(i) Administer 1 mg (1:10,000) IVP every 3 5 minutes Administer 1 mg (1:10,000) IVP/IO every 3 5 minutes 221 to 222 g) Added new dosing for dopamine replacement. 223 through 224 IV/IN/IM IO route of administration added for fentanyl 226 d) (5) Added: (5) Excited delirium 227-1 through New Addition 227-3 227-4 through Re-numbered to accommodate Ketamine. 230 234 g)(1)(c) Added medical consult symbol. 235 (5) Excited Complete revision. Delirium 236 c) Indications Added: (3) Pulmonary Edema/Congestive Heart Failure (Pediatric Only)
Morphine Sulfate Naloxone (Narcan) 237 g) Dosage Added: (3) Pediatric Pulmonary Edema/CHF (a) 0.1 mg/kg SLOW IVP/IO/IM (1-2 mg/minute). Maximum dose 5 mg. 238 (1) Adult: Administer 0.4 2 mg IVP/IO (titrated)/im/in (if delivery device is available, divide administration of the dose equally between the nares to a maximum of 1 ml per nare); repeat as necessary to maintain respiratory activity. (2) Pediatric: Administer 0.1 mg/kg IVP/IO (titrated)im/in (if delivery device is available, divide administration of the dose equally between the nares to a maximum of 1 ml per nare), up to maximum initial dose of 2 mg; may be repeated as necessary to maintain respiratory activity. ET dose: 0.2 0.25 mg/kg (1) Adult: Administer 0.4 2 mg IVP/IO (titrated)/im/in (if delivery device is available, divide administration of the dose equally between the nares to a maximum of 1 ml per nare); OR administer 4 mg/0.1 ml IN in one nare. Repeat as necessary to maintain respiratory activity. (2) Pediatric: Administer 0.1 mg/kg IVP/IO (titrated)im/in (if delivery device is available, divide administration of the dose equally between the nares to a maximum of 1 ml per nare); OR administer 4 mg/0.1 ml IN in one nare. May be repeated as necessary to maintain respiratory activity. ET dose: 0.2 0.25 mg/kg Multiple pages Verapamil CPAP EasyTube Nasotracheal Intubation Needle Decompression Thoracostomy (NDT) Ventilatory Difficulty Secondary to Bucking or Combativeness in Intubated Patients This new dosing regimen appears in multiple places throughout the s, specifically on pages 46, 47, 116, 117, 118, 120, 123, and 124. 239 through Re-numbered to accommodate Ketamine. 246 246 to 246-2 New medication for ALS providers 252 Removed duplicate title. 253 Latex-Free Dual Lumen Tube (e.g., EasyTube ) Laryngeal Tube Airway Device (KING LTS-D ) Protocol replaced, including adding of another acceptable size of the device. 256 (3) When hypovolemia is unlikely, morphine or midazolam, or a When hypovolemia is unlikely and hypotension is not present, combination of both... morphine/fentanyl or midazolam, or a combination of both 257 Purpose Needle Decompression Thoracostomy is the procedure of introducing a needle/catheter (with flutter valve attached) into the pleural space of the chest to provide temporary relief for the patient suffering from a tension pneumothorax. 265 c) (1) c) (5) Page 5 of 8 Needle Decompression Thoracostomy is the procedure of introducing a needle/catheter with a minimum length of 3.25 inches and a minimum diameter of 14 gauge (with add-on flutter valve attached) into the pleural space of the chest to provide temporary relief for the patient suffering from a tension pneumothorax. Medical consultation requirement has been removed for midazolam administration in adult and pediatric sections. Pediatric section has been renumbered (no further changes to patient care). Glucometer Protocol 279 c)(1)(b) If unable to initiate an IV and blood glucose is less than 70 mg/dl, administer glucagon 1 ml IM/IN. If unable to initiate an IV and blood glucose is less than 70 mg/dl, administer glucagon 1 mg IM/IN. Glucometer Protocol 280 Patients 28 days or greater up to the 18th birthday - if blood glucose is less than 70 mg/dl, administer 2 4 ml/kg of 25% dextrose IV/IO to a maximum of 25 grams. D25W is prepared by mixing one part of D50W with an equal volume of LR. Recheck glucose after first dose. Patients 28 days or greater up to the 18th birthday - if blood glucose is less than 70 mg/dl, administer 2 4 ml/kg of 10% dextrose IV/IO to a maximum of 25 grams. Recheck glucose after first dose. If blood glucose is less than 70 mg/dl, obtain medical consultation to administer second dose of D10W. If blood glucose is less than 70 mg/dl, obtain medical consultation to administer second dose of D25W. Procedures: High 281 through Numerous revisions, including new algorithm. Performance CPR 284-1 Procedures: Intraosseous Infusion 285 Title Fixed formatting in the title. No changes to patient care.
Procedures: Emerging Infectious Disease Pilot Protocol: Adult and Pediatric RSI Pilot Protocol: Adult RSI 320 Title Fixed formatting in the title. No changes to patient care. 328, 335, 336 Etomidate dosing 328 through 329 Pilot Protocol: Adult RSI 329 Etomidate dosing for Ventilatory Difficulty Secondary to Bucking or Combativene ss in Intubated Patients Pilot Protocol: Adult RSI 330 c) (1) Midazolam Pilot Protocol: Pediatric RSI Pilot Protocol: RSI Pharmacology Pilot Program: Tactical EMS Pilot Protocol: Pelvic Binder Device Pilot Protocol: Transport to Freestanding Emergency Medical Facility at Bulle Rock (Base Station) 336 through 338 Etomidate, if available, will be the preferred agent for patients who are aware of their surroundings and do not have hypotension or possible hypovolemia. Dose: Administer 0.3 mg/kg IVP over 30 60 seconds. May repeat 0.15 mg/kg IVP in 2 3 minutes if inadequate sedation. f) (5) Insert an approved alternative airway device (refer Alternative Airway Device Protocol). Etomidate, if available, will be the preferred agent for patients who are aware of their surroundings and do not have hypotension or possible hypovolemia. Dose: Administer 0.3 mg/kg IVP over 30 60 seconds. May repeat 0.15 mg/kg IVP every 15 minutes to a total of three doses. Etomidate, if available, will be the preferred agent for patients who are aware of their surroundings and do not have hypotension or possible hypovolemia. Dose: Administer 0.3 mg/kg IVP over 30 60 seconds. If the patient is hypotensive or provider suspects hypovolemia, the initial dose will be 0.15 mg/kg IVP over 30 60 seconds. May repeat 0.15 mg/kg IVP in 2 3 minutes if inadequate sedation. Insert an approved alternative airway device (refer to Laryngeal Mask Airway Program or Laryngeal Tube Airway Device procedure). Etomidate, if available, will be the preferred agent for patients who are aware of their surroundings and do not have hypotension or possible hypovolemia. Dose: Administer 0.3 mg/kg IVP over 30 60 seconds. If the provider suspects hypovolemia, the initial dose will be 0.15 mg/kg IVP over 30 60 seconds. May repeat 0.15 mg/kg IVP every 15 minutes to a total of three doses. Additional doses require medical consultation. f) (4)-(5) (4) If unsuccessful, resume BVM ventilation. (4) If unsuccessful, resume BVM ventilation for 30 seconds. (5) Insert a laryngeal mask airway designed to facilitate hospital placement of an endotracheal tube (see Laryngeal Mask Airway Optional Supplemental Program). 340 g) (1) (1) Adult: Administer 0.3 mg/kg IVP over 30 60 seconds. If the provider suspects hypovolemia, the initial dose will be 0.15 mg/kg IVP over 30 60 seconds. May repeat 10 mg for adult IVP after succinylcholine effects resolve and patient is bucking or combative. May repeat 10 mg for adult IVP every 15 minutes to a total of three doses. 345 through 345-20 348 through 349 348 Pilot Protocol (1) Adult: Administer 0.3 mg/kg IVP over 30 60 seconds. If the provider suspects hypovolemia, the initial dose will be 0.15 mg/kg IVP over 30 60 seconds. Ventilatory Difficulty Secondary to Bucking or Combativeness in Intubated Patients: Administer 0.3 mg/kg IVP over 30 60 seconds. If the provider suspects hypovolemia, the initial dose will be 0.15 mg/kg IVP over 30 60 seconds. May repeat 0.15 mg/kg IVP every 15 minutes to a total of three doses. Complete revision and moved from Jurisdictional Optional Protocols Moved to Programs New Protocol Page 6 of 8
Pilot Protocol: Airway Management: Video Laryngoscopy 353 2. INDICATION Video laryngoscopy and orotracheal intubation is indicated for patients who are 18 years or older. 3. CONTRAINDICATIONS Patients less than 18 years of age. 1. d) Appropriately-sized blade for the patient being intubated (New language) 2. INDICATION Video laryngoscopy and orotracheal intubation is indicated for patients who meet one or more of the following criteria and for whom appropriatelysized equipment is available: Pilot Program: Stabilization Center Pilot Program: Stabilization Center Pilot Protocol: Alternative Destination Program Pilot Protocol: "Leave Behind" Naloxone Program Program: Intranasal Naloxone for Commercial Service BLS Providers Program: Intranasal Naloxone for Commercial Service BLS Providers Program: Intranasal Naloxone for Commercial Service BLS Providers Program: Heparin Infusion for Interfacility Transport Program: Laryngeal Tube Airway Device (King LTS-D) 364 2. Presentation...If the patient is not requesting evaluation for an emergency medical condition and substance use is suspected, proceed to the Stabilization Center Inclusion Checklist. 3. CONTRAINDICATIONS Lack of an appropriately-sized laryngoscope blade for the patient being intubated....if the patient is not requesting evaluation for an emergency medical condition and substance use is suspected, including suspected opioid patients who have improved with naloxone, patient must consent to be evaluated and transported to the Stabilization Center. Then the Paramedic must complete the Stabilization Inclusion Checklist. 364 Added language: 5. If all answers are NO or medical consultation approves if a YES occurs, the patient shall be transported to the Stabilization Center. 366 through 366-9 366-10 373 through 378 Complete revision. New Protocol Title INTRANASAL NALOXONE FOR BLS PROVIDERS INTRANASAL NALOXONE FOR COMMERCIAL SERVICE BLS PROVIDERS 373 July 2014: Naloxone is required for Public Safety EMT and remains Program for EMR and BLS Commercial Services (initially implemented September 13). (EMR AND COMMERCIAL EMT) 378 July 2014: Naloxone is required for Public Safety EMT and remains Program for EMR and BLS Commercial Services (initially implemented September 13). July 2018: Naloxone is required for Public Safety EMT and EMR (October '17) and remains Program for BLS Commercial Services (initially implemented September 13). (COMMERCIAL EMT) July 2018: Naloxone is required for Public Safety EMT and EMR (October '17) and remains Program for BLS Commercial Services (initially implemented September 13). 380 7. a) a) Adult: Administer a maximum of 18 units/kg per hour. a) Adult: Administer a maximum of 18 units/kg per hour or 2,000 units per hour, whichever is higher. 381 Moved to Procedures. Page 7 of 8
Program: Laryngeal Mask Airway with Design to Facilitate Hospital Endotracheal Intubation Program: Specialty Care Paramedic Program: Tactical EMS Program: Mechanical CPR Program: Pelvic Binder Device Multiple s Program: Wilderness EMS Program: Maryland Vaccination & Testing Program Research Protocol: LAMS Stroke Protocol For Baltimore City Fire Department Research Protocol: Pediatric Destination Decision Tree 381 New Protocol. 394 B. 4. Laryngeal Mask Airway (LMA) Laryngeal Mask Airway [Removed acronym LMA] 395 through 411 395 397 through 398 413 through 417-2 418 through 442 Complete revision and moved to Pilot Programs New Moved from Pilot Protocols Protocols re-lettered to accommodate Pelvic Binder Device. Numerous revisions 443 Protocol re-lettered to accommodate Pelvic Binder Device. 450-1 through 450-3 450-4 through 450-6 New research New research Page 8 of 8